The Nursing Home as Battle Zone

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By Paula Span
In a nursing home near Denver, Sharon Kenney’s mother was waiting, and waiting, for an aide to answer her call bell and help her to the bathroom. Her daughter stayed on the phone with her for 45 increasingly desperate minutes. Finally Ms. Kenney hung up, called the desk nurse and asked that someone be sent to assist her mother. The ensuing conversation, as she recalls it:
Nurse: “We’re really busy and we have a lot of residents here. You’ll have to wait your turn.”

Ms. Kenney (after long pause): “That’s not the answer I was expecting. The answer I was expecting was, ‘I’m so sorry, we’ll send someone right down there.’”

Nurse: “I only have one person on that wing. She needs to wait.”

Ms. Kenney: “Maybe you could go down and help her. Do I have to drive over there and help her myself?”

The nurse and Ms. Kenney made peace a few days later, but whenever there’s a problem, a question, a tiff, Ms. Kenney takes notes. Her motto for dealing with the staff, even at an excellent nursing home where her mother lives happily: “Be as polite as possible. But relentless.”

On the other hand, and there is always another hand, Tracy Dudzinski, a certified nursing assistant, worked in a central Wisconsin nursing home for seven years. Interactions with residents’ relatives usually remained pleasant but, she said, “Some family members were rather rude. They thought you were their slave: ‘Do this, do that, do it now.’ They were bossy — they talked down to you. I don’t think most of them realized one aide was responsible for eight to 15 patients.”

Nursing home staff and family members tangle — how could it be otherwise? Family members, doing something no one ever really wants to do, grapple with stress, guilt and raw emotion as they turn daily care for a loved one over to strangers. And virtually all nursing homes are chronically short-staffed, with too few aides and nurses scurrying to help too many residents, who are more impaired and suffer higher rates of dementia than their peers a couple of decades ago. Even staffers who want to provide warm, personal attention rarely have the time.

“Staff and family members often have very strong stereotypes about one another,” said Karl Pillemer, a gerontologist at Cornell University who has researched these relationships for 20 years. “The staff sometimes feel families complain excessively — they’re too demanding. On the flip side, families sometimes feel that staff aren’t sufficiently caring, that staff are rude to them . . . . They often feel they have to coach the staff about how to care for their relative.”

“And then you add the situation where often staff and family are culturally different,” Dr. Pillemer continued. “They don’t come from the same socioeconomic status; they may be racially and ethnically different. Even though both share a common goal, the circumstances provide a fertile environment for conflict, anger and misunderstanding.”

Take my friend Cynthia Dyer-Bennet, usually an even-tempered sort. She grew frustrated when the aides caring for her mother in a dementia facility outside San Francisco seemed to routinely neglect brushing her teeth. “I could tell because her toothbrush was always bone-dry,” Ms. Dyer-Bennet said. The staff denied any problem. “They’d say, ‘We did brush her teeth.’ I’d say, ‘No, look, here’s her toothbrush — it’s dry at 9:30 in the morning.’ They’d lie to me.”

She understood that with three aides caring for 27 residents, the staff was doing its best. She knew, firsthand, that with an Alzheimer’s patient, brushing teeth can take 20 minutes. But she persisted, citing what she saw as broken promises about diet and activities, as well as oral hygiene. “It reached the point where the caregivers didn’t want to see me because I was waving a toothbrush, and the administrators didn’t want to see me because they didn’t want to hear complaints,” Ms. Dyer-Bennet said. She eventually moved her mother elsewhere.

Fighting with people who should be partners is miserable for all parties (and raises families’ fears that aides may retaliate by ignoring, or even harming, relatives). But the consequences go beyond mere unpleasantness, research by Dr. Pillemer and his colleagues show.

Family members who perceive conflict with staff have significantly higher levels of depression, according to a 2007 study conducted in 20 upstate New York nursing homes. And interviews with nearly 700 nursing home nurses and nursing assistants revealed that conflict with family members increases staff burnout and lowers job satisfaction, which contributes to the sky-high staff turnover rates that already plague many nursing homes.

Family-staff frictions can be ameliorated, though. Connie Kreider, a C.N.A. in Lancaster County, Pa., nursing homes for 12 years, has seen it happen. “If families see who you are, get to know you, if you ask for their opinions so they feel comfortable with you, you iron things out,” she said.

How to accomplish that ironing is a subject we’ll tackle in an upcoming post, though many of you may have your own suggestions, welcomed below.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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